Request Form
Quote for Automobile Insurance

Please be advised that the Wilkerson Insurance Group cannot bind, modify, or terminate coverage by messages transmitted via our website or email. Quotes may be obtained online, but a signature is required for all transactions. Wilkerson Insurance Group is licensed only for the state of North Carolina, and cannot give quotes for customers in other states.
Name:
Address:
City:
State:
Zip Code:
County:
Inside City Limits: Yes: No:
Home Phone:
Work Phone:
Best time to call:


Policy Information

Next Auto Renewal Date:
Current Auto Insurance Company:
Current Premium: $

Please list information for all drivers on this policy:
Date of Birth License Number

Tickets or Accidents in the last 5 years:
Date Description

Please list all vehicles for this policy:
Year/Make/Model OR Serial Number Primary Usage Comprehensive
Deductible 		Collision
Deductible